Culture-positive Spontaneous Bacterial Peritonitis Research Articles

Profile of spontaneous bacterial peritonitis in non-alcoholic fatty liver disease cirrhosis

Background: Etiology of chronic liver disease (CLD) has an impact on the profile of spontaneous bacterial peritonitis (SBP) in terms of infection acquisition, resistance pattern, and treatment outcome. Aims and Objectives: This study aimed to study infection acquisition, antibiotic resistance pattern, and treatment outcome in patients with non-alcoholic fatty liver disease (NAFLD) cirrhosis with SBP. Materials and Methods: This observational prospective study was carried out in Government Medical College; Srinagar: over a period of 2 years from 2017 onward. We did analysis of patients with NAFLDs cirrhosis. We studied infection acquisition, antibiotic resistance pattern, and treatment outcome in this group of patients. Results: Over 2-year period, 246 patients were enrolled. The mean age of patients was 57.09±13.90 years. Hepatitis B virus and NAFLD were the major etiological contributors to the burden of CLD amounting to 51.20% in Kashmir. SBP was present in 33/57 (57.90%) of NAFLD cirrhosis patients. Child-Turcotte-Pugh Class C was 63.60%. Patients with culture-positive SBP (CP-SBP) were 45.45%. In patients of SBP with etiology other than NAFLD, CP-SBP was 61% whereas culture-negative SBP was 38.77%. Conclusion: In our region, NAFLD is one of the leading contributors to CLD. In this study, the trend toward worse treatment outcome and mortality in the patients with NAFLD SBP was observed.

Neutrophil percentage-to-albumin ratio is a new diagnostic marker for spontaneous bacterial peritonitis: a prospective multicenter study

BackgroundThe neutrophil percentage-to-albumin ratio (NPAR) is a novel measure of systemic inflammation and infection. Low albumin levels increase the risk of infection, while high neutrophil counts indicate the presence of infection. Spontaneous bacterial peritonitis (SBP) is a serious infection in cirrhotic ascites, and the potential of NPAR in diagnosing SBP is not yet established.ObjectiveThe objective of this study is to determine the diagnostic value of NPAR in identifying SBP.PatientsThis prospective multicenter study included 465 patients diagnosed with cirrhotic ascites and SBP according to international guidelines. Demographic, clinical, and laboratory data were collected. The sensitivity and specificity of NPAR values for diagnosing SBP were assessed using the receiver operating characteristic curve.ResultsFor SBP diagnosis in the total cohort, NPAR of > 17 had a sensitivity of 85.71%, specificity of 66.67%, and 95% CI (42.1–99.6). In culture-positive SBP, the NPAR at a cut-off > 5.2 had a sensitivity of 85.71%, specificity of 83.33%, and 95% CI (0.709 to 0.979), while in culture-negative SBP, the NPAR at a cut-off > 2.1 had a sensitivity of 92.86%, specificity of 33.33% and CI (0.367 to 0.764). The multivariate analysis revealed that albumin (OR = 2.78, [1.11;3.98], INR (OR = 0.198, [0.066;0.596], creatinine (OR = 0.292, [0.1; 0.81], CRP (OR = 3.18, [1.239;4.52] total leukocytic count (TLC) (OR = 1.97, [1.878; 2.07], platelets (OR = 2.09, [0.99; 2.31] and neutrophil (OR = 3.43, [1.04;3.89] were significantly associated with higher prediction rates for culture positive SBP.ConclusionsNPAR could be a new, affordable, noninvasive test for diagnosing SBP.

Diagnostic role of procalcitonin serum level in hepatitis C virus-infected patients with spontaneous bacterial peritonitis

ObjectiveWe aimed at the evaluation of the role of quantification of serum procalcitonin (PCT) in the detection of spontaneous bacterial peritonitis (SBP) in hepatitis C-related cirrhosis before and after initiation of antibiotic therapy.BackgroundSBP is a lethal consequence of advanced cirrhosis. The outcome is heavily affected by early detection and treatment. PCT has been evaluated during acute bacterial infections and sepsis.Patients and methodsWe included 60 patients with ascites due to hepatitis C-related cirrhosis, who were divided in two groups: group 1 included 40 naïve patients with SBP, and group 2 included 20 patients with sterile ascites as a control. After history taking and clinical examination, full blood count, liver test profile, and renal functions were done. Moreover, C-reactive protein and erythrocyte sedimentation rate levels were measured. Serum PCT was measured by immunoassay. Diagnostic ascitic sample analysis was done for the polymorphonuclear leukocyte (PMNL) count, albumin levels, and ascetic fluid culture.ResultsSerum PCT was significantly elevated in group 1 before treatment than after treatment, as well as when compared with group 2. There was no statistically significant correlation between the change in the C-reactive protein level and that of the serum PCT before and after treatment in group 1. There is no significant correlation between increases in the serum PCT and the results of bacterial growth of ascetic fluid culture group before and after treatment.ConclusionPCT levels in the serum appear to provide a good diagnostic certainty in the diagnosis of SBP in cirrhotic patients at a cutoff value of 0.17 ng/ml for patients with either culture-positive or negative SBP.

Culture negative neutrocytic ascites versus culture positive spontaneous bacterial peritonitis; Is there a Difference; A Multi-Centric Study

Background: There are two variants of spontaneous bacterial peritonitis (SBP) include, culture negative neutrocytic ascites (CNNA) and culture positive SBP. Some suggested that, the clinical presentation of two variants is nearly similar, however, other reported that, patients with culture positive have a more severe course and higher mortality than CNNA. The aim of this study is to determine the clinical characteristics and predictors of CNNA in comparison to culture positive SBP. Materials and methods: This study included 300 consecutive patients with HCV related cirrhotic ascites. All patients underwent abdominal paracentesis and the ascitic fluid was processed for cell count and culture. Clinical and laboratory parameters of these patients were recorded at index admission.. Results: Out of 300 patients included in the study, 150 patients had SBP. Among the 150 patients with SBP, 100 patients were culture positive SBP (culture positive SBP with ascitic fluid PMNL ≥250 cells/m3) and 50 patients were CNNA (culture negative SBP with ascitic fluid PMNL ≥250 cells/m3). Compared to patients with culture positive SBP, patients with CNNA showed, a significant decrease as regards, fever, prevalence of DM, hepatic encephalopathy, platelets, blood PMNL and ascetic PMNL. Logistic regression analysis demonstrated that, decreased platelets count, blood PMNL and ascetic PMNL were independent predictor factors for CNNA. Conclusion: Patients with CNNA have a lower incidence of fever, prevalence of diabetes mellitus, hepatic encephalopathy, blood PMNL and ascetic PMNL versus culture positive SBP. Independent predictors of culture negative SBP are decreased platelets, blood PMNL and ascetic PMNL.

Spontaneous Bacterial Peritonitis in Cirrhotic Patients: A Shift in the Microbial Pattern? A Retrospective Analysis

Introduction: Over the last decade, a shift in the spontaneous bacterial peritonitis (SBP) microbial pattern toward an increasing incidence of gram-positive and multidrug-resistant (MDR) bacteria has been reported. Systematic surveillance of the local microbiological scenario and antibiotic resistance is crucial to SBP treatment success. The main objective of this study was to evaluate the microbiological profile and bacterial resistance of SBP pathogens in a Portuguese cohort to allow selection of the most appropriate empirical antibiotics. Methods: This is a single-center retrospective study including 63 adult cirrhotic patients with culture-positive SBP. Patients were identified using a hospital general diagnostic database and searching for all SBP events (neutrophil count in ascitic fluid ≥250/mm³) from January 1, 2012, to December 31, 2017. Patients were excluded if they had culture-negative SBP, secondary peritonitis, peritoneal dialysis, a liver transplant, or immunodeficiency. The site of SBP acquisition was classified as nosocomial if it was diagnosed 48 h or longer after hospitalization or as nonnosocomial if it was diagnosed within the first 48 h. MDR bacteria were those with an acquired resistance to at least 1 agent in 3 or more antimicrobial categories. All statistical analyses were carried out using IBM SPSS Statistics software version 22 (IBM, New York, USA). Results: The study cohort comprised 53 (84.1%) men. The mean age of the patients was 60.6 ± 11.2 years. Alcohol was the most common etiology (88.9%) and most patients had advanced liver cirrhosis (87.1%, Child C). Gram-negative bacteria were slightly more frequent than gram-positive bacteria (56.9 vs. 43.1%). Escherichia coli was the most common pathogen (33.8%). Nineteen (31.7%) bacteria were classified as MDR. Resistance to third-generation cephalosporins, quinolones, piperacillin-tazobactam, and carbapenems was found in 31.7, 35, 26.7, and 18.3% of the cases, respectively. The rates of gram-positive bacteria were similar between nosocomial and nonnosocomial episodes (45 vs. 42.2%; p = 0.835). MDR bacteria were more common in the nosocomial group (50 vs. 23.8%; p = 0.046). Resistance to third-generation cephalosporins (50 vs. 23.8%; p = 0.046), piperacillin-tazobactam (44.4 vs. 19.1%; p = 0.041), and carbapenems (33.3 vs. 11.9%; p = 0.049) occurred more frequently in nosocomial episodes. Resistance to first-line antibiotic occurred in 29.3% of the patients, being more common in the nosocomial group (44.4 vs. 22.5%; p = 0.089). Conclusion: Although gram-negative bacteria remain the most common causative microorganisms, our results emphasize the shift in SBP microbiological etiology, as almost half of the isolated microorganisms were gram positive. The emergence of bacteria resistant to traditionally recommended empirical antibiotics underlines the importance of basing this choice on local flora and antibiotic susceptibility data, allowing a more rational and successful use of antibiotics.

A retrospective analysis of cases of Spontaneous Bacterial Peritonitis in cirrhosis patients.

Spontaneous Bacterial Peritonitis (SBP) is an infection in patients with cirrhosis and carries significant mortality. The management of SBP is evolving with the rise of multidrug resistant organisms. Our aim was to perform a retrospective analysis to determine if identification of bacteria in culture could aid in prognosis and provide information regarding optimal treatment. We analyzed our 10-year experience of SBP in a single academic center (Northwestern Memorial Hospital). We obtained information regarding SBP prophylaxis, culture data and resistance patterns of bacteria, choice/duration of inpatient antibiotics, and key laboratory measurements and determined outcomes including mortality, hospital duration, and ICU stay. Patients with SBP had a 17.8% mortality and had culture positive SBP 34.4% of the time. Antimicrobial resistance was seen in 21.3% of cases and trended towards worsening mortality, with worsened mortality associated with first line use of piperacillin-tazobactam (p = 0.0001). Patients on SBP prophylaxis who developed SBP had improved mortality (p<0.0001) unless there was a positive culture, in which case patients had worsened mortality (p = 0.019). Patient with a higher PMN counts after repeat paracentesis had higher mortality (p = 0.02). Our results show that SBP continues to be a morbid and deadly condition and identification of an organism is key in treatment. The standard initial antibiotic for SBP may need to be modified to reflect emerging resistant pathogens and gram-positive organisms. Further, antibiotic prophylaxis should be utilized only in select cases to prevent development of resistance.

Ascitic Interleukin 6 Is Associated with Poor Outcome and Spontaneous Bacterial Peritonitis: A Validation in Critically Ill Patients with Decompensated Cirrhosis.

Decompensated cirrhosis predisposes to infectious diseases and acute-on-chronic liver failure (ACLF) in critically ill patients. Infections like spontaneous bacterial peritonitis (SBP) are frequently associated with multi-organ failure and increased mortality. Consequently, reliable predictors of outcome and early diagnostic markers of infection are needed to improve individualized therapy. This study evaluates the prognostic role of ascitic interleukin 6 in 64 patients with cirrhosis admitted to our intensive care unit (ICU). In addition, we analysed the diagnostic ability of ascitic interleukin 6 in a subgroup of 19 patients with SBP. Baseline ascitic interleukin 6 performed well in predicting 3-month mortality in patients with decompensated cirrhosis (area under curve (AUC) = 0.802), as well as in patients fulfilling ACLF-criteria (AUC = 0.807). Ascitic interleukin 6 showed a moderate prognostic advantage compared with common clinical scores and proinflammatory parameters. Moreover, ascitic interleukin 6 had a sufficient diagnostic ability to detect SBP (AUC = 0.901) and was well correlated with ascitic polymorphonuclear neutrophils in SBP (p = 0.002). Interestingly, ascitic interleukin 6 revealed a high predictive value to rule out apparent infections on admission to ICU (AUC = 0.904) and to identify patients with “culture-positive SBP” (AUC = 0.856). Ascitic interleukin 6 is an easily-applicable proinflammatory biomarker with high prognostic and diagnostic relevance in critically ill patients with liver cirrhosis.

Comparative study between spontaneous fungal peritonitis (SFP) and spontaneous bacterial peritonitis (SBP) in patients with end stage liver disease (ESLD)

Background: Bacterial infections in end stage liver disease are common and associated with increased mortality. Although extensive research has elucidated the impact of bacterial infections as the major precipitating event leads to increased frequency of liver-related complications and mortality in these patients. Objective: Evaluating the clinical and laboratory characters, risk factors, and outcome of fungal and bacterial peritonitis in cirrhotic patients with end stage liver disease (ESLD). Patients and Methods: This cross sctional study enrolled 60 patients with liver cirrhosis and ascites. Fifty patients were culture-positive spontaneous peritonitis, including 12 with spontaneous fungal peritonitis (SFP), and 38 culture-positive spontaneous bacterial peritonitis (SBP), and 10 patients without clinical or laboratory evidence of peritonitis as a control group, during the study period, between 1st February 2018 and 30th May 2019. We compared the clinical, laboratory findings, Child–Pugh scores, model for end stage liver disease (MELD) score, risk factors, and mortality rates between patients with spontaneous peritonitis associated with fungal culture-positive ascites, and those with spontaneous peritonitis associated with bacterial culture-positive ascites. Results: Patients of the current study were critically ill. The mean duration of ESLD in the studied patients was 4.75 ± 1.8 year, 57 patients (95.0%) were Child score C, and 3 patients (5%) were Child score B. The mean MELD score was 23.32 ± 5.49. All patients with evidence of peritonitis were Child C, and mean MELD scores were 22.6 ±5.7 and 26.1±4.5 in SBP and SFP groups respectively. Jaundice, GI bleeding and hepatic encephalopathy were significantly for clinical presentation and predictors of mortality in SFP group compared to SBP and control group. Lower levels of hemoglobin (Hb), S. albumin and platelets count and increased level of total leukocytic count (TLC), international normalized ratio (INR), and bilirubin were significantly higher in SFP group compared to SBP and control group. Duration of ESLD and hospital admission was significant in SFP compared to SBP and control group. HCC was evident in SFP group (66.7%) that was highly significant in comparison to SBP (28.9%), and control group (20%). Overall mortality rate among the studied groups was 45%, the mortality rate was significantly increased in SFP group (75%) compared to SBP (42.1%), and control group (20%).The mean MELD score significantly increased in non-survival group compared to survival group . The duration of ESLD significantly increased in non-survival group compared to survival group. Conclusion: Prolonged and severe underlying liver disease with a high Child- Pugh or MELD score, renal impairment, HCC, and onset of severe sepsis have been reported as risk factors in increased mortality in patients with SFP than in SBP. In SFP, mortality was associated not only with the severity of the underlying liver disease, but also with delay in diagnosis and initiation of antifungal therapy.

Comparative study between spontaneous fungal peritonitis (SFP) and spontaneous bacterial peritonitis (SBP) in patients with end stage liver disease (ESLD)

Background: Bacterial infections in end stage liver disease are common and associated with increased mortality. Although extensive research has elucidated the impact of bacterial infections as the major precipitating event leads to increased frequency of liver-related complications and mortality in these patients. Objective: Evaluating the clinical and laboratory characters, risk factors, and outcome of fungal and bacterial peritonitis in cirrhotic patients with end stage liver disease (ESLD). Patients and Methods: This cross sctional study enrolled 60 patients with liver cirrhosis and ascites. Fifty patients were culture-positive spontaneous peritonitis, including 12 with spontaneous fungal peritonitis (SFP), and 38 culture-positive spontaneous bacterial peritonitis (SBP), and 10 patients without clinical or laboratory evidence of peritonitis as a control group, during the study period, between 1st February 2018 and 30th May 2019. We compared the clinical, laboratory findings, Child–Pugh scores, model for end stage liver disease (MELD) score, risk factors, and mortality rates between patients with spontaneous peritonitis associated with fungal culture-positive ascites, and those with spontaneous peritonitis associated with bacterial culture-positive ascites. Results: Patients of the current study were critically ill. The mean duration of ESLD in the studied patients was 4.75 ± 1.8 year, 57 patients (95.0%) were Child score C, and 3 patients (5%) were Child score B. The mean MELD score was 23.32 ± 5.49. All patients with evidence of peritonitis were Child C, and mean MELD scores were 22.6 ±5.7 and 26.1±4.5 in SBP and SFP groups respectively. Jaundice, GI bleeding and hepatic encephalopathy were significantly for clinical presentation and predictors of mortality in SFP group compared to SBP and control group. Lower levels of hemoglobin (Hb), S. albumin and platelets count and increased level of total leukocytic count (TLC), international normalized ratio (INR), and bilirubin were significantly higher in SFP group compared to SBP and control group. Duration of ESLD and hospital admission was significant in SFP compared to SBP and control group. HCC was evident in SFP group (66.7%) that was highly significant in comparison to SBP (28.9%), and control group (20%). Overall mortality rate among the studied groups was 45%, the mortality rate was significantly increased in SFP group (75%) compared to SBP (42.1%), and control group (20%).The mean MELD score significantly increased in non-survival group compared to survival group . The duration of ESLD significantly increased in non-survival group compared to survival group. Conclusion: Prolonged and severe underlying liver disease with a high Child- Pugh or MELD score, renal impairment, HCC, and onset of severe sepsis have been reported as risk factors in increased mortality in patients with SFP than in SBP. In SFP, mortality was associated not only with the severity of the underlying liver disease, but also with delay in diagnosis and initiation of antifungal therapy.

Clinical features and outcomes of bacterascites in cirrhotic patients: A retrospective, multicentre study.

Current guidelines on the management of bacterascites are limited. This multicentre, retrospective study investigated the clinical features and outcomes of cirrhosis patients with bacterascites. Two series of cirrhosis patients were evaluated. The first included 418 patients with ascites-positive cultures at 11 hospitals during 2012-2018. Clinical characteristics and outcomes were recorded. The second included 208 patients with sterile ascites from a prospective cohort (NCT02457637). Clinical features and outcomes of cirrhotic patients with or without bacterascites were investigated. In the first series, bacterascites was diagnosed in 254/418 (60.8%) patients, and culture-positive spontaneous bacterial peritonitis (SBP) in 164/418 (39.2%) patients. Gram-positive bacteria were more prevalent in bacterascites patients than in culture-positive SBP patients (59.1% vs 22.0%; P<.001). For patients with acute-on-chronic liver failure (ACLF) in bacterascites and culture-positive SBP groups, the 28-day transplant-free mortality (41.3% vs 65.5%; P=.015) and the prevalence of in-hospital acute kidney injury (AKI) (84.8% vs 75%; P=.224). For patients without ACLF in the bacterascites (n=208) and culture-positive SBP groups (n=108), the 28-day transplant-free mortalities were 13% vs 13.9% (P=.822), the probabilities of progression to ACLF within 28days were 10.1% vs 14.8% (P=.216) and the prevalences of in-hospital AKI were 14.4% vs 30.6% (P=.001). Bacterascites patients had higher 28-day mortality than those patients with sterile ascites, after propensity score matching (18.4% vs 8.6%; P=.010). Bacterascites patients had non-negligible poor clinical outcomes, including in-hospital AKI, progression to ACLF and 28-day mortality. Future studies are warranted to expedite the diagnosis of bacterascites and optimize antibiotic treatment.

Vitamin D and LL-37 in cirrhotic patients with culture-positive spontaneous bacterial peritonitis

EnBackground and aimsSpontaneous bacterial peritonitis (SBP) is a common bacterial infection in patients with liver cirrhosis and ascites. Cirrhotic patients frequently have vitamin D (Vit-D) deficiency. Vit-D induces the production of LL-37, an important molecule of innate immunity, in macrophages. The aim of this study is to assess Vit-D and LL-37 levels in the ascitic fluid (AF) of cirrhotic patients with SBP in comparison to patients with simple ascites.Patients and methodsForty male cirrhotic patients with ascites were included and were divided into two groups, 20 with culture-positive SBP (group I) and 20 with simple ascites (group II). AF Vit-D and LL-37 levels were measured.ResultsVit-D and LL-37 levels were significantly lower in patients with SBP than those with simple ascites. In univariate analysis, the risk factors for SBP were lower platelet count, higher leukocytic count, higher serum bilirubin, lower prothrombin activity, lower serum albumin, higher Child–Pugh and model for end-stage liver diseases scores, and lower AF Vit-D and LL-37 levels, while in multivariate analysis, a lower AF Vit-D level was the only risk factor for SBP.ConclusionPatients with SBP have lower levels of AF Vit-D and LL-37 than simple ascites, where an inadequate expression of LL-37 in AF due to the low Vit-D level may increase the susceptibility to SBP.

Prevalence and Predictors of Third-Generation Cephalosporin Resistance in the Empirical Treatment of Spontaneous Bacterial Peritonitis

ObjectiveTo better characterize the changing patterns of spontaneous bacterial peritonitis (SBP) in a tertiary academic center in the United States by identifying the prevalence of gram-positive organisms and cephalosporin resistance along with predictors of mortality and antibiotic drug resistance. Patients and MethodsWe reviewed 481 consecutive patients with SBP at Mayo Clinic in Rochester, Minnesota, from January 1, 2005, through December 31, 2016. Data on comorbid conditions, etiology of cirrhosis, factors predisposing to infection, and antimicrobial and antibiotic drug use were collected. ResultsWe identified 96 patients (20%) with culture-positive SBP requiring treatment (median age, 60 years; age range, 22-87 years; 44% men). Gram-positive organisms account for more than half of the cases. Overall resistance to third-generation cephalosporins was 10% (n=10). Risk factors for third-generation cephalosporin resistance include nosocomial acquisition, recent antibiotic drug use, and hepatocellular carcinoma. The negative predictive value for antibiotic drug resistance in the present model was 96% (70 of 73). Overall mortality at 30 and 90 days was 23% and 37%, respectively. ConclusionThese findings support the recent observation of a rising prevalence of gram-positive organisms in SBP. Despite the changing pattern, third-generation cephalosporins seem to provide adequate empirical treatment in patients with community-acquired and health care–associated SBP without hepatocellular carcinoma.

Spontaneous bacterial peritonitis recurrence in patients with cirrhosis receiving secondary prophylaxis with norfloxacin.

Few studies carried out more than 20 years ago have evaluated spontaneous bacterial peritonitis (SBP) recurrence in patients receiving secondary antibiotic prophylaxis. These studies reported a 1-year recurrence rate of 20-26%. Changes in the bacteriology of SBP over the last few years might have negative effects on secondary prophylaxis. Our primary aim was to estimate the incidence of SBP recurrence in patients with cirrhosis receiving secondary prophylaxis with norfloxacin and to explore the factors associated with SBP recurrence. This was a retrospective cohort study of patients receiving norfloxacin for the secondary prophylaxis of SBP from 1 March 2003 to 31 March 2016. Follow-up was performed for 365 days after secondary prophylaxis was started. A competing risk analysis approach was used. A total of 115 patients were included. The prevalence of quinolone-resistant and multiresistant bacteria in the first episode of SBP among patients with culture-positive SBP was 70.96% [95% confidence interval (CI): 51.96-85.77%] and 12.90% (95% CI: 3.63-29.83%), respectively. The cumulative incidence of SBP recurrence was 28.53% (95% CI: 20.15-37.45%) after 365 days. Male patients showed an estimated subhazard ratio of SBP recurrence of 2.52 (95% CI: 1.07-5.91, P=0.034). No other risk factors for SBP recurrence were identified. The overall cumulative incidence of death after 365 days was 21.57% (95% CI: 14.14-30.04%), without significant differences among patients with or without SBP recurrence. Even though changes in the bacteriology of SBP occurred over time, its recurrence rate in patients receiving norfloxacin remains similar to what was reported in the initial studies.

Evidence of Significant Ceftriaxone and Quinolone Resistance in Cirrhotics with Spontaneous Bacterial Peritonitis

There are few studies addressing the impact of cephalosporin and quinolone resistance on hospital length of stay and mortality in spontaneous bacterial peritonitis (SBP). We aim to describe the shifting epidemiology of SBP at our institution and its impact on clinical outcomes. We performed a single-center retrospective cohort study of all cases of SBP from 2005 to 2015 at a transplant center. Cases were identified using hospital billing data. Patient data were confirmed using the electronic medical record. Univariate and multivariate logistic regression and Cox proportional hazards models were used to identify factors that were associated with prolonged hospital length of stay and reduced survival. Culture-positive cases (N = 56) were compared to culture-negative cases (N = 104). Subpopulation analysis of the culture-positive cases compared ceftriaxone-resistant (N = 25) to ceftriaxone-susceptible (N = 31) cases. We identified 160 cases of SBP (56 culture positive and 104 culture negative; 21 nosocomial, 79 hospital associated, and 60 community acquired). Forty-five percent (N = 25 total, 13 hospital associated and 6 nosocomial) of bacterial isolates were resistant to ceftriaxone, with 37.5% (N = 21) being gram positive, including 8 methicillin-resistant staphylococcus and 6 vancomycin-resistant enterococcus. Multivariate analysis identified hospital-associated SBP, age, alcoholic cirrhosis, and MELD-Na score as variables associated with worse survival (P < 0.05), with a trend toward worse survival in culture-positive cases (P = 0.123). Only MELD-Na was associated with prolonged length of stay. The burden of resistant pathogens causing SBP is significant, notably in hospital-associated SBP. Culture-positive SBP may represent a higher risk group compared to culture-negative SBP.

Noninvasive screening identifies patients at risk for spontaneous bacterial peritonitis caused by multidrug-resistant organisms.

Background and aimsSpontaneous bacterial peritonitis (SBP) is a severe complication of decompensated cirrhosis. The prevalence of multidrug-resistant organisms (MDROs) in patients with cirrhosis is increasing. Identification of patients at risk for SBP due to MDROs (ie, SBP with the evidence of MDROs or Stenotrophomonas maltophilia in ascitic culture, MDRO-SBP) is crucial to the early adaptation of antibiotic treatment in such patients. We therefore investigated whether MDROs found in ascitic cultures can also be found in specimens determined by noninvasive screening procedures.Patients and methodsThis retrospective study was conducted at the liver center of the University Hospital Frankfurt, Germany. Between 2011 and 2016, patients with cirrhosis were included upon diagnosis of SBP and sample collection of aerobic/anaerobic ascitic cultures. Furthermore, the performance of at least one complete MDRO screening was mandatory for study inclusion.ResultsOf 133 patients diagnosed with SBP, 75 (56.4%) had culture-positive SBP and 22 (16.5%) had MDRO-SBP. Multidrug-resistant Escherichia coli (10/22; 45.5%) and vancomycin-resistant enterococci (7/22; 36.4%) resembled the major causatives of MDRO-SBP. Rectal swabs identified MDROs in 17 of 22 patients (77.3%) who developed MDRO-SBP with a time-dependent sensitivity of 77% and 87% after 30 and 90 days upon testing, while negative predictive value was 83% and 76%, respectively. The majority of patients were included from intensive care unit or intermediate care unit.ConclusionMDRO screening may serve as a noninvasive diagnostic tool to identify patients at risk for MDRO-SBP. Patients with decompensated cirrhosis should be screened for MDROs from the first day of inpatient treatment onward.

Combination of PCT, sNFI and dCHC for the diagnosis of ascites infection in cirrhotic patients

BackgroundIt is difficult to diagnose ascites infection early in cirrhotic patients. The present study was to create and evaluate a new bioscore combined with PCT, sNFI and dCHC in the diagnosis of ascites infection in cirrhotic patients.MethodsTwo hundred and fifty-nine consecutive patients were enrolled; of which 51 patients were culture-positive spontaneous bacterial peritonitis (culture-positive SBP) and 58 patients were culture-negative SBP. The efficacy of procalcitonin(PCT), c-reactive protein (CRP), white blood cell (WBC), mean fluorescence intensity of mature neutrophils(sNFI) and difference in hemoglobin concentration between newly formed and mature red blood cells(dCHC) for diagnosing ascites infection was examined. These parameters were used to create a scoring system. The scoring system was analyzed by logistic regression analysis to determine which parameters were statistically different between ascites infection and non-ascites infection patients. Receiver operating characteristic curve (ROC) was used to analyze the diagnostic ability of bioscore for ascites infection.ResultsIn ROC analysis, the area under the curves (AUC) for PCT was 0.852 (95% CI 0.803–0.921, P < 0.001), dCHC 0.837 (95% CI 0.773–0.923, P < 0.001), CRP 0.669 (95% CI 0.610–0.732, P = 0.0624), sNFI 0.838 (95% CI 0.777–0.903, P < 0.001), and WBC 0.624 (95% CI 0.500–0.722, P = 0.0881). Multivariate analysis revealed PCT, dCHC and sNFI to be statistically significant. The combination of these three parameters in the bioscore had an AUC of 0.937 (95% CI 0.901–0.994, P < 0.001). A bioscore of ≥3.40 was considered to be statistically significant in making a positive diagnosis of ascites infection. In different groups of ascites infection, bioscore also shown a high diagnostic value of AUC was 0.947(95% CI 0.882–0.988, P < 0.001) and 0.929 (95% CI 0.869–0.974, P < 0.001) for culture-positive SBP and culture-negative SBP group respectively.ConclusionThe composite markers of combining PCT, dCHC and sNFI could be a valuable diagnostic score to early diagnose ascites infection in patients with cirrhosis.

Prevalence and predictors of spontaneous bacterial peritonitis due to ceftriaxone-resistant organisms at a large tertiary centre in the USA.

The epidemiology of spontaneous bacterial peritonitis (SBP) due to ceftriaxone-resistant organisms has not been well studied in the USA. The primary objective of this study was to assess the prevalence and predictors of ceftriaxone-resistant SBP at a large US tertiary-care centre. This 1:1:4 case-case-control study included 141 adults with liver cirrhosis admitted from November 2011 to March 2016. Case group 1 were patients with SBP with a ceftriaxone-resistant organism (n=21). Case group 2 were patients with SBP with a ceftriaxone-susceptible organism (n=26). The control group were patients without SBP (n=94). Multiple logistic regression analysis was used to identify predictors of ceftriaxone-resistant SBP. Fifty isolates were identified from 47 patients with culture-positive SBP (case groups 1 and 2). Of these 50 isolates, 32 (64%) were Gram-negatives [mostly Enterobacteriaceae (91%)], 15 (30%) were Gram-positives and 3 (6%) were Candida spp. The prevalence of ceftriaxone resistance in patients with culture-positive SBP was 45% (21/47). The most common ceftriaxone-resistant organisms were ESBL-producing Enterobacteriaceae (45%). Independent predictors of ceftriaxone-resistant SBP included duration of β-lactam therapy in the past 90days (aOR=1.07, 95% CI 1.01-1.13) and recent invasive gastrointestinal procedure (aOR=12.47, 95% CI 2.74-56.67). The prevalence of ceftriaxone-resistant SBP was significant at a US tertiary centre. Local epidemiological data and identification of risk factors associated with ceftriaxone-resistant SBP, e.g. increased usage of previous β-lactam therapy and invasive gastrointestinal procedure, may help clinicians identify patients requiring alternative empirical antibiotics.

Retrospective Comparative Study of Spontaneous Peritonitis Associated with Fungal and Bacterial Infection in Patients with Liver Cirrhosis

Objective: Although patients with liver cirrhosis (LC) have a high risk of developing bacterial and fungal infections, few studies have evaluated spontaneous fungal peritonitis (SFP) or fungiascites in this population. Accordingly, we conducted a retrospective comparative study of spontaneous peritonitis associated with fungal (SFP and fungiascites) or bacterial culture-positive ascites [spontaneous bacterial peritonitis (SBP) and bacterascites] in patients with LC.Methods: This study enrolled 73 patients with LC and ascitic culture-positive spontaneous peritonitis, including four, three, 35, and 31 patients with SFP, fungiascites, culture-positive SBP, and bacterascites, respectively. We compared the laboratory findings, Child–Pugh scores, and 1-month mortality rates between patients with fungal disease, i.e., spontaneous peritonitis associated with fungal culture-positive ascites (SFP and fungiascites), and those with bacterial disease, i.e., spontaneous peritonitis associated with bacterial culture-positive ascites (culturepositive SBP and bacterascites).Results: We observed no significant differences in the severity of underlying liver dysfunction and renal impairment between patients with fungal and bacterial disease. However, the 1-month mortality rate was significantly higher in patients with fungal disease than in those with bacterial disease (71.4%, 5/7 vs. 25.8%, 17/66; p= 0.038).Conclusion: In our retrospective study population, spontaneous peritonitis caused by fungi (SFP and fungiascites) was associated with a significantly higher short-term mortality rate compared with that of spontaneous peritonitis caused by bacteria (culture-positive SBP and bacterascites). Further studies are required to investigate the underlying mechanisms and determine the effects of antifungal therapy on mortality.

Features and Outcomes of Spontaneous Bacterial Peritonitis in Egypt, Single Center Experience

Spontaneous bacterial peritonitis (SBP) is a serious complication of liver cirrhosis, with a recurrence rate up to 70% at 1 yr. Diagnosis of SBP is based on a positive ascitic fluid (AF) culture and/or a polymorph nuclear leukocyte count of >250 cells/μL. Third generation cephalosporins had been viewed as the drug of choice. Aim of the work: to study features, and outcomes of spontaneous bacterial peritonitis in National Liver Institute (Menofia University), a single center study. Methods: This work was conducted on 60 patients had SBP. All patient had AF analysis, bedside AF culture, Blood culture (BC), Serum albumin, Ascitic fluid gradient (SAAG). Results: The more severe the liver disease, as assessed by Child-Turcotte-Pugh (CTP score), the higher the possibility to have positivity of AF culture. Patient who had positive BC had significant rising of Creatinine. The pattern of infection in AF culture is close to that of BC, but Streptococci take the upper hand in BC and Staphylococcus in AF culture. Gram-positive organisms are more common in both AF and BC than gram negative. Mortality rate was higher in culture positive SBP patients 46.2%, and BC positive patients, 62.5%. In all positive cultures patients, Staph Species represents 44.8% with mortality rate of 42% of all mortalities. Most of them were resistant to cephalosporin 62.5%. Strep species represents 31% with mortality rate of 20%. E. coli represents 24.2% with mortality rate of 20%. Conclusion: The microbial pattern of organisms responsible for SBP has changed with predominance of gram-positive organisms. Pattern of microbial infection is similar in both blood and ascetic fluid culture, so BC results can be relied upon to guide therapy, in negative AF culture.

Extensively drug-resistant bacteria are an independent predictive factor of mortality in 130 patients with spontaneous bacterial peritonitis or spontaneous bacteremia.

To evaluate the epidemiology and outcomes of culture-positive spontaneous bacterial peritonitis (SBP) and spontaneous bacteremia (SB) in decompensated cirrhosis. We prospectively collected clinical, laboratory characteristics, type of administered antibiotic, susceptibility and resistance of bacteria to antibiotics in one hundred thirty cases (68.5% males) with positive ascitic fluid and/or blood cultures during the period from January 1, 2012 to May 30, 2014. All patients with SBP had polymorphonuclear cell count in ascitic fluid > 250/mm(3). In patients with SB a thorough study did not reveal any other cause of bacteremia. The patients were followed-up for a 30-d period following diagnosis of the infection. The final outcome of the patients was recorded in the end of follow-up and comparison among 3 groups of patients according to the pattern of drug resistance was performed. Gram-positive-cocci (GPC) were found in half of the cases. The most prevalent organisms in a descending order were Escherichia coli (33), Enterococcus spp (30), Streptococcus spp (25), Klebsiella pneumonia (16), S. aureus (8), Pseudomanas aeruginosa (5), other Gram-negative-bacteria (GNB) (11) and anaerobes (2). Overall, 20.8% of isolates were multidrug-resistant (MDR) and 10% extensively drug-resistant (XDR). Health-care-associated (HCA) and/or nosocomial infections were present in 100% of MDR/XDR and in 65.5% of non-DR cases. Meropenem was the empirically prescribed antibiotic in HCA/nosocomial infections showing a drug-resistance rate of 30.7% while third generation cephalosporins of 43.8%. Meropenem was ineffective on both XDR bacteria and Enterococcus faecium (E. faecium). All but one XDR were susceptible to colistin while all GPC (including E. faecium) and the 86% of GNB to tigecycline. Overall 30-d mortality was 37.7% (69.2% for XDR and 34.2% for the rest of the patients) (log rank, P = 0.015). In multivariate analysis, factors adversely affecting outcome included XDR infection (HR = 2.263, 95%CI: 1.005-5.095, P = 0.049), creatinine (HR = 1.125, 95%CI: 1.024-1.236, P = 0.015) and INR (HR =1.553, 95%CI: 1.106-2.180, P = 0.011). XDR bacteria are an independent life-threatening factor in SBP/SB. Strategies aiming at restricting antibiotic overuse and rapid identification of the responsible bacteria could help improve survival.